The short answer, according to officials at the Alabama Department of Public Health, is that a large segment of the state's population lives in rural areas where hospitals are few and far between.

"In metropolitan areas, they have plenty of traffic accidents but they're very close to hospitals," said Dr. Jim McVay, director of health promotion and chronic disease at the ADPH.

"The real danger is being in a traffic accident on a rural road."

If you're injured in a car accident in a rural area, it may take many precious minutes for an ambulance to reach you, while every minute is critical. If your accident is severe enough that it requires the "jaws of life" or other specialized equipment to pull you free, it could take even longer.

Once EMTs arrive and stabilize you for transport, they may have another long drive to get you to a hospital - any hospital - that can treat your injuries.

"What we're talking about is the 'golden hour,'" said Dale Quinney, information specialist at the Alabama Rural Health Association. "When you have someone who is a victim in a car crash, the likelihood of survival is greatly enhanced if you can get them to a trauma center within an hour following the accident."

A direct relationship

According to the Alabama Rural Health Association, the motor vehicle accident mortality rate for rural Alabama residents is nearly 56 percent higher than it is for Alabama's urban residents.

"There's a direct relationship," said Quinney, "between how rural a county is and the survival rate from motor vehicle accidents."

According to the ADPH's Center for Health Statistics, Alabama's average rate of motor vehicle fatalities (per 100,000 population) for 2011-2013 is 18.9. This number, unlike the CDC number, takes into account all persons injured in a car wreck; not just the car's occupants. For comparison, the national rate for that time period is 11.4.

But while Alabama's rate of 18.9 is high, the numbers get worse when you zoom in on the state's most rural areas.

Lee County, located less than an hour east of Montgomery, had the lowest vehicle mortality rate in the state during the 2011-2013 time period, at 9.9.

Compare that with nearby - but much more rural - Wilcox County, about an hour and a half west of Montgomery. Wilcox has a staggering vehicle fatality rate of 55.6 - five times the national average.

Adjacent Lowndes County has a rate of 55.1. Lowndes is one of eight counties in the state that doesn't have a hospital.

Rural hospitals shut doors

Financial and other problems over the past few decades have forced more and more rural hospitals to close their doors, or to sharply curtail the services they provide. McVay said he can think of five hospitals in Alabama that have closed in the past six years; 10 in the past 10 years.

According to Quinney, Alabama and Georgia are tied for having the second-highest number of hospitals that closed in the past six years, behind Texas.

"There's a direct correlation (between) bad outcomes and the loss of emergency rooms in particular to stabilize an injury situation," said McVay. "All the more reason to continue to have medical care in a rural area, particularly (to improve outcomes from car accidents)."

Other factors

Whether or not a county has a hospital is just one - albeit large - piece of the puzzle.

"Sometimes those ambulances can't even go to the closest hospital," said McVay. "If they're dealing with severe trauma, a small rural hospital might not have the right staff to treat that."

And there are lifestyle factors. McVay pointed out that in rural areas, people tend to travel longer distances to social events and other places. More time on the road can increase the chances of getting in an accident.

Quinney said there's also speed to consider.

"In rural areas, there's a tendency to go faster," he said, "so if you have an impact, (the damage) is going to be more serious."

A matter of education

Men are 2.5 times more likely to die in vehicle crashes than women, and young people ages 18-24 are the age demographic with the highest fatality rates.

But Quinney said one marker that has often been overlooked is education.

"Among victims age 25 or higher, the highest motor vehicle fatality rate is for those with less than a ninth-grade education, and it is 50.6," said Quinney. When looking strictly at educational status for ages 25+, the vehicle fatality rate decreases as educational attainment increases. The fatality rate for college graduates is just 10.4.

"Here in Alabama, we are trying to keep our rural health facilities open tomorrow and we aren't concentrating on the longterm," said Quinney. "The solution (to better health outcomes in Alabama) is a better-educated population."

He points out that the overall death rate - across all causes of death - for people 25 and older is more than twice as high for those with less than a ninth grade education as it is for those with a high school diploma; four times higher than it is for people with a college education.

"If we had a better-educated population, you would have the opportunity for higher incomes and greater access to healthcare," said Quinney. "That is the longterm solution."